Provider Demographics
NPI:1366441032
Name:CHISHOM, PATRICE GIBSON (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:GIBSON
Last Name:CHISHOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICE
Other - Middle Name:DANNETTE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4112 E PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-8106
Mailing Address - Country:US
Mailing Address - Phone:404-289-7133
Mailing Address - Fax:404-289-7211
Practice Address - Street 1:4112 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-8106
Practice Address - Country:US
Practice Address - Phone:404-289-7133
Practice Address - Fax:404-289-7211
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045185208000000X
SC18331208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics